OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to investigate injuries of unknown cause and document how abuse was ruled out for 2 of 3 sampled residents (#s 1 and 2) with wounds or injuries that were discovered by or reported to the facility. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2022 with diagnoses including history of cerebrovascular accident (CVA or stroke), hemiparesis (partial weakness from the stroke), vascular dementia, and had a recent femur/hip fracture. The service plan indicated the resident required two-person assistance for transfers. Progress notes and incident reports indicated the resident repeatedly self-transferred without calling for assistance, and the resident was found on the floor 19 times between 01/16/26 and 04/13/26 with non-injury incidents. Review of the resident’s record indicated the following: a. On 02/09/26 a facility MT transcribed a hospice visit note into the resident’s progress notes which noted hospice had identified a skin tear to Resident 1’s right shin. There was no documented evidence the facility investigated this injury to determine how it occurred and to rule out the injury was the result of abuse or neglect. b. On 04/04/26 a facility MT documented the presence of a bruise to Resident 1’s left arm. There was no documented evidence the facility investigated this injury to determine how it occurred and to rule out the injury was the result of abuse or neglect. The injuries were reviewed with Staff 2 (Assistant ED) and Staff 3 (Director of Assisted Living) on 04/15/26 at 1:50 pm. They reviewed the record and stated in both cases that the resident was found on the floor either earlier that day or the previous day, and that was how the injuries occurred. They acknowledged they did not document that rationale for how they ruled out abuse. The need to investigate injuries and wounds to determine how they occurred and to rule out they were the result of abuse was reviewed with Staff 1 (ED), Staff 2, Staff 3, Staff 4 (RN) and Staff 18 (Enliven Director) on 04/16/26 at 12:00 pm. They acknowledged the facility had failed to investigate how the injuries may have occurred. 2. Resident 2 was admitted to the facility in 01/2024 with diagnoses including dementia, heart disease, recurrent falls, left below-the-knee amputation and peripheral vascular disease. Review of the resident’s record indicated the following: a. On 02/14/26, a facility MT transcribed a HH nurse visit note that identified multiple scattered/scabbed wounds to the resident’s right lower extremity (RLE), an open scab on the kneecap, and an open, macerated, nickel-sized wound towards the end of his/her stump. There was no documented evidence the facility investigated these wounds to determine how they occurred and to rule out the wounds were the result of abuse or neglect. b. On 04/09/26, a facility MT documented a “dark, quarter-sized spot” on the resident’s shin. That same day, the staffing coordinator transcribed a note from the HH nurse that indicated the resident had two small new wounds with surrounding redness on his/her RLE. There was no documented evidence the facility investigated these injuries and wounds to determine how they occurred, and to rule out the injuries and wounds were the result of abuse or neglect. During an interview on 04/16/26 at 9:40 am, Staff 4 (RN) stated, “It’s not been on my radar to do an incident report [investigation] when home health finds a skin issue.” The need to investigate injuries and wounds to determine how they occurred and to rule out they were the result of abuse or neglect was reviewed with Staff 4 (RN) on 04/15/26 at 9:40 am, and with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Director of Assisted Living) on 04/15/26 at 11:30 am. They acknowledged the facility had failed to investigate how the injuries and wounds may have occurred.

1) Injuries of unknown cause will be reported and promptly investigated to rule out abuse for both resident(s) 1 and 2. If there are no findings on how the injury(s) occurred, the injury(s) will be reported to ODHS. 2) Health Services staff will be in-serviced on proper reporting of injury(s) of all residents. Incidents of injury(s) will be promptly investigated, with proper documentation for any and all injury(s). 3) Incident reports will be reviewed daily. 4) Brianne Fowler, Director of Assisted Living. Chelsea Tschida, Assisted Executive Director. Shannon Lang, Executive Director.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine, document, and communicate to staff what actions or interventions were needed for a resident following a change of condition, note progress of the condition at least weekly until resolved, monitor each resident consistent with his or her evaluated needs and service plan, for 2 of 5 sampled residents (#s 1 and 2) who had documented changes of condition related to skin issues and falls. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2022 with diagnoses including history of cerebrovascular accident (CVA or stroke), hemiparesis (partial weakness from the stroke), vascular dementia and a recent femur/hip fracture. Review of the resident’s record indicated the following: a. Staff documented on 02/09/26 that hospice had noted the presence of a skin tear to Resident 1’s right shin and documented on 04/04/26 the presence of a bruise to Resident 1’s left arm. There was no documented evidence the facility determined and documented what actions were needed for the resident, communicated those actions to staff, and monitored and documented on the progress of the injuries at least weekly until the conditions were resolved. In an interview on 04/15/26 at 1:50 pm, Staff 2 (Assistant ED) and Staff 3 (Director of Assisted Living) stated Resident 1 should have been placed on alert charting and a temporary service plan (TSP) should have been written and shared with staff that instructed staff to monitor the resident for pain, latent injuries and changes in mobility, ADLs and mental status. b. Resident 1 had 19 documented falls between 01/16/26 and 04/13/26. The resident’s current service plan, dated 01/16/26, included the following fall interventions: * Two-person assistance for all transfers; * Use of bilateral half-length side rails to hold onto; and * Remind the resident to use the call light for assistance and wait for staff. The facility did not consistently document it monitored that the service-planned interventions were being followed at the time of the falls. c. Progress notes indicated the facility implemented the following additional interventions to address Resident 1’s falls: * A fall mat placed next to the resident’s bed; * Bed placed in lowest position; * Positioning the resident’s bed against the wall for safety; * The use of a scoop mattress: and * Implementing safety checks throughout the day and night. Observations of the resident and an interview with Staff 16 (CG) on 04/15/26 at 1:15 pm confirmed the use of the fall mat, bed positioning and scoop mattress. Staff 16 stated she checked on the resident approximately every 30 minutes for safety. There was no documented evidence the facility documented and communicated these new interventions to staff either by updating the service plan itself or by documenting the new interventions in temporary service plans. The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed for a resident following a change of condition, noted progress of the condition at least weekly until resolved, monitored each resident consistent with his or her evaluated needs and service plan was reviewed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Director of Assisted Living), and Staff 18 (Enliven Director) on 04/15/26 at 1:50 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2024 with diagnoses including dementia, heart disease, recurrent falls, left below the knee amputation and peripheral vascular disease. Review of the resident’s record indicated the following: Resident 2’s service plan indicated s/he was independent with transfers but benefitted from CG assistance with shower transfers to line up with the shower chair. The service plan indicated the resident was very determined, independent, and resistant to assistance. On the following dates the resident had falls for which the facility failed to monitor whether new interventions or additional service plan updates needed to be added to prevent future falls: * 02/03/26; * 02/13/26; * 02/23/26; * 03/09/26; and * 03/17/26. On 04/16/26 at 2:50 pm, Staff 3 (Director of Assisted Living) confirmed that their investigations into the falls did not include whether new interventions or additional service plan updates were needed to be added to prevent future falls. The need to ensure the facility monitored each resident consistent with his or her evaluated needs and service plan and provided written communication of any new interventions to direct care staff was reviewed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 on 04/15/26 at 11:30 am. They acknowledged the findings.

1) Change of condition(s) for resident 1 and 2 will be monitored and documented with applicable fall/risk interventions specific to each resident and communicated to staff through TSP's so they are aware of the change in resident(s) status. 2)Health Services staff (med techs) will be in-serviced on how to complete proper documentation related to reported changes of condition from outside providers, internal staff or resident reports. Nurses to review outside provider notes to ensure all propoer steps are exicuted related to change of condition. 3)Every time there is a report of a resident change of condition or when there is a outside provider note turned in. 4) Brianne Fowler, Director of Assisted Living. May Agular, LPN. Vicki Brigham, RN. Chelsea Tschida, Assistant Executive Director. Shannon Lang, Executive Director.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and these PRN medications were used only after documented, non-pharmacological interventions had been tried with ineffective results for 1 of 1 sampled resident (#1) who was prescribed and administered PRN psychotropic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 2022 with diagnoses including history of cerebrovascular accident (CVA or stroke), hemiparesis (partial weakness from the stroke), vascular dementia, and a recent femur/hip fracture. The resident was prescribed two PRN psychotropic medications to address his/her medical symptoms and behavior: * Haloperidol (an antipsychotic medication) as needed for agitation/hallucinations or nausea/vomiting; and * Lorazepam (used to treat anxiety) as needed for anxiety/insomnia. a. The 03/2026 and 04/2026 MARs lacked resident-specific parameters that described how the resident exhibited “agitation,” “hallucinations,” and “anxiety.” b. Between 03/01/26 and 04/13/25, the resident was administered the PRN haloperidol seven times. There was no documented evidence non-pharmacological interventions have been tried with ineffective results prior to administering the medication. In an interview on 04/14/26 at 3:25 pm, Staff 19 (Staffing Coordinator) stated the new eMAR software the facility was using required the MT to document in a progress note that they or the caregivers had attempted non-drug interventions prior to administering a PRN psychotropic medication. The need to ensure PRN psychotropic medications included written, resident-specific parameters and that they were only used after documented, non-pharmacological interventions had been tried with ineffective results was reviewed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Director of Assisted Living), Staff 4 (RN) and Staff 18 (Enliven Director) on 04/16/26 at 12:00 pm. They acknowledged the findings.

1) Community nurses will review and implement resident specific non-psychotropic interventions prior to administration of medication(s) unless otherwise indicated by the resident provider for resident #1. 2) Ongoing the community nurses will conduct weekly audits of all PRN psychotropic medications to ensure that the orders have listed resident specific non-psychotropic interventions. 3) Weekly 4) Brianne Fowler, Director of Assisted Living. May Agular, LPN. Vicki Brigham, RN. Chelsea Tschida, Assistant Executive Director. Shannon Lang, Executive Director.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: